Account Setup – WeCare Pharmacy

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Practitioner Name(Required)

First Last

DEA Number(Required)

If not applicable, please write N/A.

NPI Number(Required)

License Number(Required)

Upload License(s)(Required)

Max. file size: 300 MB.

Upload scanned copies of licenses.

Practice Name(Required)

Clinic Specialty

Do you work with a Medical Director?(Required)

Medical Director

Medical Director NPI Number(Required)

Medical Director DEA Number(Required)

If not applicable, please write N/A.

Medical Director License Number(Required)

Upload License(s)

Max. file size: 300 MB.

Upload scanned copies of licenses.

Are you under the supervision of another licensed physician?

Physician Name(Required)

First Last

Physician NPI Number(Required)

Physician DEA Number(Required)

If not applicable, please write N/A.

Physician License Number(Required)

Upload License(s)

Max. file size: 300 MB.

Upload scanned copies of licenses.

Practice Owner

Promo or Conference Code

Account Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Account Email Address(Required)

Phone(Required)

Fax

Username(Required)

Password(Required)

Enter Password Confirm Password

Signature(Required)

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

32229